1. Field of the Invention
The present invention relates generally to medical methods and apparatus for treating breast tissues. More particularly, the present invention relates to methods and apparatus for ablating or inhibiting the proliferation of epithelial and other cells lining a breast duct.
Breast cancer is the most common cancer in women, with well over 100,000 new cases being diagnosed each year in the United States alone. Breast cancer usually begins in the cells lining a breast duct, with the first stage thought to be excessive proliferation of individual cell(s) leading to xe2x80x9cductal hyperplasia.xe2x80x9d Some of the hyperplastic cells may then become atypical, with a significant risk of the atypical hyperplastic cells becoming neoplastic or cancerous. Initially, the cancerous cells remain in the breast ducts, and the condition is referred to as ductal carcinoma in situ (DCIS). After a time, however, the cancerous cells are able to invade outside of the ductal environment, presenting the risk of metastases, which can be fatal to the patient.
While breast cancer through the DCIS phase is in theory quite treatable, effective treatment requires both early diagnosis and an effective treating modality. At present, mammography is the state-of-the-art diagnostic tool for detecting breast cancer. Often, however, mammography is only able to detect tumors, which have reached a size in the range from 0.1 cm to 1 cm. Such a tumor mass may be reached as long as from 8 to 10 years following initiation of the disease process. Detection of breast cancer at such a late stage is often too late to permit effective treatment.
Alternative diagnostic modalities, which promise much earlier detection of breast cancer and DCIS, are described in co-pending application Ser. Nos. 08/931,786; 09/067,661; and 09/301,058, the full disclosures of which are incorporated herein by reference. Together, these applications describe techniques for identifying one or more (usually all) individual ductal orifices on a nipple in a breast and for collecting cellular and other materials from individual ductal networks to determine if hyperplasia, DCIS, or other abnormal conditions are present in that network. While these techniques will be very useful in providing early and accurate diagnosis of breast cancer and other diseased conditions, they do not directly provide for treatment of the condition once it is diagnosed.
Conventional treatments for breast cancer have been focused on the treatment of a latter stage disease and include removal of the breast, localized removal of the tumor (xe2x80x9clumpectomyxe2x80x9d), radiation, and chemotherapy. While these techniques are often very effective, they suffer from certain deficiencies. Removal of the breast provides the best assurance against recurrence of the cancer, but is disfiguring and requires the patient to make a very difficult choice. Lumpectomy is less disfiguring, but is associated with greater risk of recurrence of the cancer. Radiation and chemotherapy are arduous and are not completely effective against recurrence. Such conventional treatments will not always be able to take full advantage of emerging diagnostic techniques, which promise to allow detection of pre-cancerous and cancerous conditions in the breast at a very early stage.
For these reasons, it would be desirable to provide improved and alternative techniques for treating breast cancer and pre-cancerous conditions such as ductal carcinoma in situ (DCIS) and atypical ductal hyperplasia (ADH). In particular, it would be desirable to provide treatment modalities, which can be used in conjunction with the newly developed techniques for diagnosing DCIS and other abnormal conditions within individual breast ducts. Such techniques should be less invasive and traumatic to the patient than the present techniques, should result in minimum or no disfigurement of the breast, and should be effective locally within target sites within the breast duct and/or throughout an entire ductal network. Preferably, the techniques should be capable of being performed in a single or very few treatment session(s). At least some of these objectives will be met by the invention described hereinafter.
2. Description of the Background Art
Co-pending application Ser. Nos. 08/931,786; 09/067,661; and 09/301,058 have been described above. Publications by the inventor herein relating to breast duct access include Love and Barsky (1996) Lancet 348: 997-999; Love (1992) xe2x80x9cBreast duct endoscopy: a pilot study of a potential technique for evaluating intraductal disease,xe2x80x9d presented at 15th Annual San Antonio Breast Cancer Symposium, San Antonio, Tex., Abstract 197; Barsky and Love (1996) xe2x80x9cPathological analysis of breast duct endoscoped mastectomies,xe2x80x9d Laboratory Investigation, Modern Pathology, Abstract 67. A description of the inventor""s earlier breast duct access work was presented in Lewis (1997) Biophotonics International, pages 27-28, May/June 1997.
Nipple aspiration and/or the introduction of contrast medium into breast ducts prior to imaging are described in Sartorius (1995) Breast Cancer Res. Treat. 35: 255-266; Satorius et al. (1977) xe2x80x9cContrast ductography for the recognition and localization of benign and malignant breast lesions: An improved technique,xe2x80x9d in: Logan (ed.), Breast Carcinoma, New York, Wiley, pp. 281-300; Petrakis (1993) Cancer Epidem. Biomarker Prev. 2: 3-10; Petrakis (1993) Epidem. Rev. 15: 188-195; Petrakis (1986) Breast Cancer Res. Treat. 8: 7-19; Wrensch et al. (1992) Am. J. Epidem. 135: 130-141; Wrensch et al. (1990) Breast Cancer Res. Treat. 15: 39-51; and Wrensch et al. (1989) Cancer Res. 49: 2168-2174. The presence of abnormal biomarkers in fine needle breast aspirates is described in Fabian et al. (1993) Proc. Ann. Meet. Am. Assoc. Cancer Res. 34: A1556. The use of a rigid 1.2 mm ductoscope to identify intraductal papillomas in women with nipple discharge is described in Makita et al. (1991) Breast Cancer Res. Treat. 18: 179-188. The use of a 0.4 mm flexible scope to investigate nipple discharge is described in Okazaki et al. (1991) Jpn. J. Clin. Oncol. 21: 188-193. The detection of CEA in fluids obtained by a nipple blot is described in Imayama et al. (1996) Cancer 78: 1229-1234. Delivery of epithelium-destroying agents to breasts by ductal cannulation is described in WO 97/05898 and U.S. Pat. No. 5,763,415.
A company called Diagnostics Inc., formed in 1968, produced devices to obtain breast ductal fluid for cytological evaluation. The devices included a breast nipple aspiration device to collect NAF (nipple aspirate fluid) from subjects, and catheters to retrieve ductal fluid from breast ducts. The devices were sold prior to May 28, 1976 for the purpose of collecting breast ductal fluid for cytological evaluation.
Energy-mediated ablation of the uterus, gall bladder, blood vessels, and other hollow body organs are described in the following U.S. Pat. Nos.: 4,776,349; 4,869,248; 4,872,458; 4,979,948; 5,045,056; 5,100,388; 5,159,925; 5,222,938; 5,277,201; 5,242,390; 5,403,311; 5,433,708; 5,507,744; and 5,709,224.
The present invention provides improved methods for treating individual milk ducts in human and animal breasts. Such treatments will usually be performed in patients diagnosed with cancer or precancerous conditions but may also find use prophylactically in patients at risk of cancer or other ductal diseases. Treatment is directed at individual ducts in ductal networks within the breast and typically comprises transferring energy to or from a lumen of the duct in an amount sufficient to destroy (ablate) or inhibit proliferation of cells lining the duct, such as epithelial cells which are atypical, excessively proliferating (neoplastic), and/or at risk of excessive proliferation. In an exemplary embodiment, high frequency electrical current is directed to the lumen in order to ablate or necrose at least a portion of the cellular lining of the duct. The present invention also encompasses directing other forms of energy to the lumen of the duct, including light energy, vibrational energy (e.g., ultrasonic or sonographic), radiation (electromagnetic, ultraviolet, infrared, nuclear (typically xcex2 but some times xcex1 and/or xcex3), x-ray, etc.), heat, direct electrical current, microwave, ferromagnetic, and the like. Cryogenic treatment may also find use with suitable cryogenic delivery systems as described, for example, in U.S. Pat. Nos. 5,899,898 and 5,147,355, the full disclosures of which are incorporated herein by reference. Photodynamic therapy employing light with wavelengths from ultraviolet to infrared may find use with known photoactive agents, such as porfimer sodium (PHOTOFRIN(copyright)), lutetium texaphrin (Antrin(copyright)), temoporfin (Foscan(copyright)), aminolevulinic acid HC1 (Levulan(copyright)), and the like. Exemplary phorphyrins and methods of making and other potential aids in the process of using them against breast cancer are described in U.S. Pat. Nos. 4,935,498, 5,159,065, 5,292,414, 5,369,101, 5,439,570, 5,451,576, 5,457,183, 5,530,122, 5,567,687, 5,587,371, 5,587,463, 5,607,924, 5,756,726, 5,776,925, 5,801,229, 5,817,017, and 5,837,866. Usually, the photoactive agent will be directed into an individual ductal network and light radiation directed to the ductal network and/or the entire breast. For example, the light may be introduced into the ductal network using a light fiber or waveguide in the form of a ductal access tool. Alternatively or additionally, light can be directed onto and through the exterior of the breast.
Other forms of energy and radiation may also be utilized to activate or enhance the activity of drugs and active agents which have been introduced into the ductal lumen(s). For example, ultrasonic energy may be used, e.g., to excite a fluid or material that is inside the duct. The fluid or material can then act upon the duct, including the ductal lining. For example, polymers which are sensitive to ultrasonic energy can be administered to a breast duct. The present invention provides intraductal delivery of the polymer spheres, and localized or intraductal exposure of the duct or breast to ultrasound to achieve the diagnostic or therapeutic purpose. If the polymers are beads that house a cavity, the cavity can be filled with a diagnostic or therapeutic material which is delivered to the breast duct. When exposed to ultrasonic energy the polymer wall breaks down and the bead disperses the material that was carried inside the polymer. Such beads are available from Point Biomedical located in San Carlos.
Photodynamic therapy (PDT) may be practiced by intravenous (systemic) delivery or intraductal delivery of a photoactivatable material followed by exposure to light that activates the material. In this invention, a PDT drug, such as, for example, Lutex is delivered via catheter into one or more mammary ducts. At the desired time, light of the appropriate frequency is applied to the outer surface of the breast or intraductally using a fiber optic. The most desirable frequencies of light are in the range of 700 nm to 800 nm which is the range that provides the highest penetration depth in tissue and blood. The light activates the PDT drug and the therapeutic effects begin after the drug is activated.
The invention also provides for the delivery of radiosensitizers that enhance radiation treatment. A radiation sensitizer can be administered to the duct or systemically. The sensitizer can be, for example, gadolinium which goes through an electron reduction forming a free radical when exposed to x-ray or gamma radiation. Texaphyrin can be combined with gadolinium to form a metallotexaphyrin (see U.S. Pat. No. 5,801,229) which is available from Pharmacyclics, Inc. The toxicity of gadolinium is further increased when exposed to the gamma or x-rays. The radiation sensitizer need not be metallic-based, but may also be a drug or chemical which enhances a cell""s susceptibility to radiation, such as CMNa (a nitroimidazole compound, see U.S. Pat. Nos. 5,650,442, and 4,820,844), carboplatin (see U.S. Pat. No. 5,780,653), or gemcitabine.
Radioisotopes can be delivered to the duct. A radioisotope can be delivered alone or conjugated to an antibody that is specific for a tumor or lesion antigen. The antigen can be, for example, a ductal epithelial cell surface molecule, or a cell surface protein that is expressed on the surface of transformed cells. The radioisotope can be conjugated to a monoclonal antibody which is capable of targeting breast ducal epithelial cell epitopes, e.g., the antibodies HER2 (see Ross and Fletcher, Oncologist 3(4):237-252 (1998); Pegram et al., Oncogene 18(3):2241-51 (1999)) or MUC1 (Chu and Chang, Cancer Lett 142:121-7(1999); Goldenberg and Nabi, Semin Nuci Med 29:41-(1999)). The radioisotope can be a particle emitting isotope, e.g., an alpha particle emitting radioisotope, e.g., Bismuth-213 (Bi-213). Alpha emitting radioisotopes are preferred because alpha particles have a short penetration depth (typically 3-6 layers of cells), are easily shielded, the present minimal radiation risks during handling. The alpha particles generated during the degradation of Bi-213 are particles with sufficient energy to ablate a limited radius of cells in the ductal lumen and surrounding the duct (e.g., myoepithelial cells, basal cells or stromal cells), and has a short half-life, about 45 minutes. Additionally, Bi-213 decays into stable Bi-209 which is approved for use in humans (and is biocompatible) and is routinely used in pharmaceuticals. To target specific lesions identified in a duct, any atypical ductal cells retrieved from a duct can be tested for antigens, and an appropriate antibody conjugated to the Bi-213 molecules for administration into the duct and specific targeting to the lesion.
Heating the breast duct (and/or fluid in the duct) may be provided in a number of ways. Heating the duct may be provided by intraductal access of a laser equipped ductal access tool for generating enough laser energy intraductally to ablate the ductal lumen tissue, including any lesions present in the duct. Preliminary work by radiologist Steven Harms at University of Arkansas has shown that laser ablation of tumors is possible and effective. Additionally, laser heating to ablate breast lesions is described in Robinson et al., J Am Coll Surg 186(3):284-292 (1998).
Radiowaves at particular frequencies or microwaves may be used to preferentially heat a medium in the breast ducts and thus ablate the ductal tissue but not other breast tissue distal from the duct. For example a fluid or material with a resonance frequency of that of an electromagnetic source (e.g., radiofrequency and microwave, etc.) can be administered to a breast milk duct. Upon application of the electromagnetic energy (either intraductally, or to the entire breast) the fluid or material in the duct with the resonance frequency that corresponds to that of the electromagnetic source would resonate the heat. The heat would destroy the ductal system that contains the resonating fluid or material. The amount of heating is controlled by the amount of electromagnetic energy applied. Metallic fluids such as gold or silver colloid can be used, for example, as the fluid or material placed into the duct to resonate at a particular electromagnetic frequency.
Microwave heating of the breast duct can also be accomplished with a breast duct access tool capable of generating a local heat that affects only the lesion and surrounding tissue of the ductal lumen. A company called Celsion, located at Columbia, Md., is developing this particular version of hyperthermia therapy.
The methods are described for application in broken tissue, whereas the present invention provides methods to apply the ablative therapy intraductally.
The present invention still comprises removing energy from the cellular lining of the duct, e.g., freezing the cellular lining, using cryogenic apparatus and methods. Agents of extreme cold, or agents which draw heat from surrounding tissue that contact the agent can be applied locally to the breast duct using a cryo-probe adapted for ductal access to ablate a lesion in the duct or other luminal tissue. A company called Endocare, Inc. is developing a CRYOcare 1xe2x80x94Probe Surgical system for administration to surgical incision sites. The Endocare product may be adapted for administration to an accessed breast duct instead of a surgical site. Extreme cold is applied through administration of a cryo agent to the ductal lumen resulting in an ablation of the ductal tissue that contacts the agent. See the care website www.ecare.org for more information about this procedure generally. See also article by Brown, J. Nat""l Cancer Inst. 90(5):351-353 (1998).
Additionally, Titan Corp. of San Diego and Tomo Therapeutics has developed an x-ray needle its subsidiary. More information about the tool and therapy is found on the internet. The tool may be applied or modified for use intraductally, to therapeutically ablate ductal tissue comprising a lesion.
Brachytherapy has been described to treat local breast disease. The brachytherapy described can be modified for administration intraductally, without incision or tissue removal. Dr. Robert Kuske is completing work along these lines at Ochsner Clinic in New Orleans, La., as described by Reuters Health Information web report Nov. 9, 1998.
Finally, radiofrequency (RF) therapy can be applied intraductally. A ductal access tool capable of delivering radiofrequency waves can be introduced into a breast duct and radiofrequency waves can be delivered to the duct to ablate tissue in the ductal lumen, including any lesion.
In a first specific aspect of the present invention, a method comprises selecting an individual duct and transferring energy to or from cells lining the duct in an amount sufficient to destroy or inhibit proliferation of said cells. The individual duct is usually selected based on a prior diagnosis or evaluation of that duct indicating a presence or risk of DCIS or other cancer within the duct. Particular methods for accessing individual ducts through an associated orifice in the nipple and for diagnosing abnormal conditions within the duct are described in prior application Ser. Nos. 08/931,786, 09/067,661, and 09/301,058, the full disclosures of which have previously been incorporated herein by reference. Briefly, at least one and usually all ductal orifices in the nipple of a breast are first located and marked using localization techniques. The lumens of each of the ductal networks can then be accessed using small diameter catheters which permit collection of cellular and other materials. By evaluating the cellular and other materials which are collected, the presence or risk of disease within an individual ductal network can be evaluated. Those individual ducts which are diseased or at risk of disease can then be selected for treatment according to the methods of the present invention.
While it will frequently be desirable to locate and screen all of the ductal orifices as just described, in certain cases it will be necessary to screen only pre-selected ductal orifices, e.g. those which display indications suggesting that they may be pre-cancerous or otherwise of particular interest. For example, it may be possible to identify regions of the breast or even particular ductal orifices which have conditions such as calcification indicating that only certain ductal orifices need to be screened. In some instances, it may even be possible to identify particular ductal networks and associated network orifices for treatment by the methods of the present invention without performing a specific ductal screening technique, e.g. using mammography, ultrasound, magnetic resonance imaging (MRI), or other ductal non-specific screening technique.
Depending on the nature of the diagnosis, the entire ductal network or only a portion thereof can be treated. To treat a portion of the ductal network, the transfer of energy will preferably be limited to the cells lining only that portion. Usually, however, it will be desirable to treat substantially the entire ductal network and energy will be transferred to or from the cells lining the entire ductal lumen.
When applying high frequency or other forms of electrical energy to the ductal lumen, it will usually be desirable to first introduce an electrically conductive medium, such as saline, electrically conductive contrast medium, or the like, to substantially fill (and usually distend) the entire duct. Methods utilizing dual lumen catheters for flushing and filling ductal networks are described in co-pending application Ser. No. 09/067,661 and 09/301,058. Once the ductal network has been filled with the electrically conductive medium, an electrode or other electrically conductive member can be introduced to the lumen, typically through the ductal orifice, and current flow established through the conductive medium to reach substantially all portions of the cellular lining. In the case of radiofrequency and other electrical energy treatments, a xe2x80x9cmonopolarxe2x80x9d energy or current flow will usually be established. That is, the electrically conductive medium within the ductal network will be connected to one pole of a suitable radiofrequency or other power supply, while the other pole is connected to a dispersive electrode which is placed on the patient""s skin, preferably over at least a portion of the breast, and more preferably over a region which circumscribes the breast. Alternatively, the dispersive electrode can be placed on the patient""s thigh, or over the lower back, percutaneously with the breast tissue, or in any other manner typically used in monopolar electrosurgical procedures.
Electrical energy could also be applied in a bipolar fashion with a first pole spaced-apart from a second pole within the lumen. In that way, electrical energy could be focused with a well defined length of the lumen.
While electrical energy will usually be delivered into the electrically conductive medium within the ductal network directly using electrode(s), it will also be possible to selectively heat the medium within the ductal network using radiofrequency induction. A radiofrequency antenna or other source, optionally shaped to conform to the exterior of the breast, may be used to selectively excite and heat the conductive medium which has been delivered into the breast. As breast tissue is primarily water, such conductive heating will generally be useful to raise the ductal temperature to very high temperatures, but rather be useful to selectively increase the temperature relative to the rest of the duct to inhibit cellular proliferation. Energy may also be transferred to the breast by introducing energy active species, such as photodynamic species, followed by a subsequent treatment of the breast using ultraviolet or other light or radiation having a wavelength selected to excite the introduced photodynamic or other species. It will be appreciated that the present invention is directed at the ductal-specific delivery of energy to the ductal network and may comprise a wide variety of specific techniques for such delivery.
The agent can comprise an agent sensitive to vibrational energy, for example, collagen spheres that break-up upon a diagnostic level of ultrasound applied to the breast or ductal lumen.
The energy will be applied in an amount and over a time sufficient to at least inhibit cellular proliferation of cells lining the ductal lumen, usually epithelial cells lining the lumen. More usually, the energy will be applied in order to necrose all cells lining the ductal lumen. Usually, at least the inner layer of epithelial cells which line and are directly exposed in the ductal lumen will be effected, usually being destroyed. Often, it will be further desirable to treat and usually destroy an epithelial layer below the first layer, and in some instances it may even be desirable to destroy the myoepithelial layer or beyond. The electrical energy will typically be applied at a power level from about 50 W to 300 W, usually from about 120 W to 200 W. The power may be applied continuously, or may be applied at a duty cycle typically in the range from 10 percent to 90 percent, often from 25 percent to 75 percent. Optionally, the amount of power delivered can be controlled based on preselected algorithms and/or feedback control algorithms. For example, the amount of power delivered to the duct could be controlled based on the temperature of the ductal lining, the temperature of the electrically conductive medium within the duct, electrical impedance between electrodes, or other measured values taken during the treatment protocol.
In addition to various forms of electrical energy, the present invention may provide for delivery of other forms of radiation, including electromagnetic, ultraviolet, infrared, nuclear, x-ray, and the like. In particular, nuclear radiation can be delivered using a solution, dispersion, sol, seeds, or other form of radio isotopic medium which can be introduced into and throughout the ductal lumen, typically using a syringe, a infusion catheter, or other device. Nuclear radiation may also be delivered to the ductal lumen using a radioactive catheter, wire, stent, implantable seed, or the like. Catheters may be designed to immobilize a nuclear radiation source, where the source may then be advanced through the ductal lumen to selectively expose portions of the luminal wall. Alternatively, or additionally, catheters may provide delivery paths for introducing nuclear materials, where the materials may be transported within the catheter to provide the desired treatment times and regions. Infrared and ultraviolet radiation may be delivered using suitable light fibers and other optical systems. X-ray energy can be delivered using a miniaturized x-ray source which can be introduced and translated through at least selected portions of the ductal lumen system.
Systems according to the present invention for applying high frequency or other electrical current to a breast duct comprise a lumen electrode, a dispersive electrode, and optionally conductive fluids to be introduced into the ductal network. The lumen electrode will be adapted to enter a lumen of the duct, typically through the associated ductal orifice, but alternatively percutaneously through tissue into the duct. The lumen electrode may be a simple single wire or filament electrode, with the primary requirement being the ability to carry sufficient power to the ductal lumen, i.e., within the power ranges set forth above. The dispersive electrode will be adapted for placement on and conformance to a region on the patient""s skin, usually on the breast, more usually circumscribing the breast, but alternatively on other locations, such as the lower back, thigh, abdomen, or the like. The system may further comprise a sheath having a lumen for introducing the lumen electrode through the ductal orifice. The sheath will typically be composed of an electrically insulating material, and the electrode will be advanced out a distal tip of the sheath in order to contact the electrically conductive medium that has been introduced to the ductal lumen, as described above. Suitable electrically conductive fluids include saline, Ringer""s medium, lactate solution, and other physiologically acceptable electrolyte. Usually, from 0.1 ml to 10 ml, typically 0.5 ml to 5 ml will be introduced into a single ductal network, and systems and kits may include vials, syringes and other containers holding pre-measured amounts of the conductive fluids. Optionally, the system may further comprise a high frequency electrical power supply having a first pole for connection to the lumen electrode and a second pole for connection to the dispersive electrode. The power supply may incorporate control features to implement the control protocols described above.
The present invention further comprises kits for treating a breast duct. The kits will usually comprise a probe, such as a lumen electrode, and optionally a dispersive electrode and conductive fluids as just described. In addition, the kits will include at least instructions for use, usually in a printed format, more usually being printed on a separate piece of-paper packaged together with the kit, or printed on a portion of the kit packaging. The instructions will set forth a method for treating a breast duct as generally described above, where the probes used to transform energy to or from the duct. The kit may further comprise a suitable package, usually in the form of a pouch, tray, box, tube, or other conventional package structure. Usually, although not necessarily, at least the electrode component of the kit will be sterilized and maintained in a sterile condition within the kit, e.g., usually being maintained in a sterile package or sterile portion of the package. The instructions for use may set forth any of the protocols set forth above in connection with the description of the methods of the present invention.
While the present invention is particularly useful for delivering energy to the ductal network in an amount and for a time sufficient to destroy at least a portion of the epithelial or other cellular lining of the ductal lumens, as described above, the invention will also find use in treating cancers and other conditions which extend beyond the cellular lining of the ductal network.